Diagnostic and Therapeutic Roles of Microdochectomy and Subareolar Ducts Excision for Pathological Nipple Discharge in Lagos

BACKGROUND

Pathological nipple discharge (PND) comprises less than 10% of presentation in breast clinics. Data on the management of nipple discharge (ND) in our environment are scarce.

AIM

To review management outcome in cohorts of patients with PND in our institution between December 2010 and October 2020.

METHODOLOGY

This is a retrospective review of consecutive patients managed for PND between 2010 and 2020. Demographical characteristics, clinical features, investigation results and management outcome were retrieved from the clinical records for analysis. A cross-sectional survey via telephone conversation/clinic consultation was carried out to monitor patients for post-operative complications and recurrence.

RESULTS

There were 25 patients (18 microdochectomies and 7 subareolar duct excisions) in the study with a median age of 44 (37.5-49.5) years. The median duration of symptoms before presentation was 3 (2.5-5.5) months. The major characteristics of ND in the study cohort were: single duct orifice in 18 patients (72%) spontaneous ND in 14 patients (56%); right ND in 15 patients (60%); and bloody ND in 21 patients (84 %). Only one patient had a family history of breast cancer. Intraductal papilloma diagnosed in 9 patients (36%) was the most common cause of PND. Breast cancer was an underlying aetiology in 28% of patients in the series. Six out of 7 patients with breast cancer diagnosis were <50years.

CONCLUSION

Most women with PND in our practice were young with predominance of spontaneous bloody discharge. Intraductal papilloma was the most common cause of PND in this study. Breast cancer accounted for about a third of cases.

Development and practice of laparoscopic surgery in a Nigerian tertiary hospital

Background

For the benefits of less postoperative pain, early recovery and discharge, and better cosmesis, laparoscopic surgery is rapidly gaining acceptance amongst surgeons as a better alternative to traditional open procedures. In January 2015, bookings for laparoscopic surgery became a more regular feature on our operation list.

Aims

We reported the indications, management outcome, and challenges in patients who had laparoscopic surgery in our institution. This is to document the trends in our surgical practice.

Methodology

This is a descriptive study of 137 patients who had laparoscopic surgery for general surgical indications in our institution over a period of 5 years. Patients data as collected from the records department were evaluated for demographic characteristics, medical comorbidities, type of procedures done, and perioperative outcome. Data analysis was performed using Statistical Package for Social Sciences (SPSS).

Results

A total of 137 Patients had laparoscopic general surgery between January 2015 and December 2019. There were 48 males and 89 females with a male-to-female ratio of 1:1.9. The mean age of the patients was 38.8 ± 3.4 years (range 16-87 years). Laparoscopic cholecystectomy (35%) and laparoscopic appendicectomy (29.9%) were the most common procedures performed. Five (3.7%) cases were converted to open surgery. Superficial surgical site infection (5.8%) following laparoscopic appendicectomy was the most common postoperative complication. There was no 30-day postoperative mortality.

Conclusion

Laparoscopic surgery is safe and can be applied to wide variety of general surgical conditions in developing countries. Minimal postoperative morbidity of laparoscopy is a major benefit to the patients.

Knowledge and prevalence of risk factors for arterial hypertension and blood pressure pattern among bankers and traffic wardens in Ilorin, Nigeria

BACKGROUND

High job strain, mental stress, sedentary lifestyle, increase in BMI are among the factors associated with significantly higher incidence of hypertension. The job of bank employees is both sedentary in nature and accompanies high mental stress. The aim of this study is to assess the level of knowledge of risk factors among respondents and to compare the blood pressure pattern of bankers and traffic wardens.

METHODOLOGY

The study design is a descriptive cross-sectional conducted among bankers and traffic wardens in Ilorin to determine the pattern and knowledge of blood pressure. Self-administered questionnaires, weighing scale (Omron Digital scale), stadiometer and sphygmomanometer were used as the research instruments. Simple random sampling was used to select respondents involved in the study.

RESULTS

The prevalence of hypertension in this study was 34.4% in bankers and 22.2% in traffic wardens. The risk factors the bankers commonly had knowledge of are alcohol, obesity, high salt intake, certain drugs, stress, emotional problems and family history while the traffic wardens commonly had knowledge of all these in addition to cigarette smoking. Also, more bankers (32.2%) than traffic wardens (13.3%) were smoking cigarette and more of these cigarette smokers that are bankers (17.8%) had elevated blood pressure compared to the traffic wardens (3.3%).

CONCLUSION

Workers in the banking industry as well as traffic wardens should be better educated about the risk factors of hypertension and bankers should be encouraged to create time for exercise.

KRAS and BRAF mutations in Nigerian colorectal cancers

PURPOSE

Activation of the KRAS oncogene is implicated in colorectal carcinogenesis and mutations have been reported in 30-50% of cases. BRAF mutation, though less common, is also reported and importantly associated with shorter progression-free interval. This study aims to determine the KRAS and BRAF mutation statuses of Nigerian colorectal cancers (CRC).

METHODS

Mutation analysis was carried out on archival paraffin-embedded blocks of CRC tissues. KRAS codons 12, 13 and 61 and BRAF V600E were assessed by pyrosequencing after DNA extraction from 200 cases at the Leeds Institute of Molecular Medicine, St. James's University Hospital, UK. Mutation rates and the spectra were determined.

RESULTS

Pyrosequencing was successful in 112 of 200 cases. KRAS mutation in codons 12 and 13 was demonstrated in 23 of 112 cases (21%); none in codon 61. BRAF mutation in codon 600 was demonstrated in 4.5%.

CONCLUSION

This study shows that 21% of Nigerian CRC patients carry a KRAS mutation; half the rate in Caucasians; and that BRAF mutation also occurs in Nigerian CRC cancers.

Intravesical migration of a failed and forgotten intrauterine contraceptive device after 20 years of insertion--a case report

Intrauterine contraceptive device (IUCD) is a commonly utilized reversible contraceptive technique especially in the developing world. Though effective, it is not immune to complications. Migration of the device is a rare but serious complication which may be symptomatic or asymptomatic. We report a case of a 45 yr old woman who had IUCD inserted 20 years earlier and had forgotten about it since she subsequently had three full-term pregnancies leading to successful vaginal deliveries. The forgotten IUCD was discovered incidentally during evaluation of the woman for haematuria as it had migrated to the wall of the bladder. The case is reported to increase index of suspicion as detailed clinical history is important in evaluating cases of haematuria.

Intravesical migration of a failed and forgotten intrauterine contraceptive device after 20 years of insertion--a case report

Intrauterine contraceptive device (IUCD) is a commonly utilized reversible contraceptive technique especially in the developing world. Though effective, it is not immune to complications. Migration of the device is a rare but serious complication which may be symptomatic or asymptomatic. We report a case of a 45yr old woman who had IUCD inserted 20 years earlier and had forgotten about it since she subsequently had three full term pregnancies leading to successful vaginal deliveries. The forgotten IUCD was discovered incidentally during evaluation of the woman for haematuria as it had migrated to the wall of the bladder. The case is reported to increase index of suspicion as detailed clinical history is important in evaluating cases of haematuria.

Acute appendicitis in Lagos: a review of 250 cases

OBJECTIVES

Acute appendicitis is common. This prospective study of 250 cases of acute appendicitis was performed to critically analyse the pattern of presentation, management, operative findings and treatment outcome. The effect of length and position of the appendix in relationship to acute inflammation was also determined.

PATIENTS AND METHODS

Two hundred and fifty cases of acute appendicitis were studied, including those found to have appendicitis at surgery despite other preoperative diagnosis. Patient biodata, clinical signs and symptoms were recorded. Haematological and biochemical parameters were determined after which all patients with a diagnosis of acute appendicitis had appendicectomy under general anaesthesia. All relevant peri-operative data were recorded. Excised appendices were sent for histological examination.

RESULTS

There were 133 males and 117 females giving a gender ratio of 1.2:1. The mean age was 25.7 +/- 10.3 years, with majority of cases (42.8%) occurring in the third decade of life. Abdominal pain (100%), fever (48.4%), anorexia (48.0%), vomiting (47.8%) were the common symptoms. Commonly elicited signs included right iliac fossa direct tenderness (74.4%), rebound tenderness (59.2%), localised guarding (42.8%) and right rectal wall tenderness (43.2%). The mean white cell count was not significantly elevated (mean 8538 +/- 4166 per mm3, P > 0.05). Sixty three percent (156/245) of all appendices were retrocaecal in position. Mean length of the appendices was 10.4 +/- 2.9 cm. The length and position of appendices were not significantly different between those who had acutely inflamed and normal appendices (P = 0.923) Two hundred and forty five patients (98%) with a diagnosis of acute appendicitis had appendicectomy. The commonest postoperative complication was wound infection (8%), overall complication rate was 13.5% and negative appendicectomy rate was 13.4%.

CONCLUSION

The presentation, management and treatment outcome of acute appendicitis in our centre are similar to those of other centres in our sub-region. Complication rates were low.

Haemosuccus pancreaticus as a rare initial manifestation of pancreatic carcinoma

BACKGROUND

The major symptoms of cancer of the pancreas, even those of the head, are insidious weight loss, abdominal pains, back pain, anorexia, nausea, vomiting and generalized malaise. Jaundice is present in about 90% of the patients with cancer of the head and 10-40% of those with cancer of body and tail. Massive haemorrhage is an uncommon presentation. Most causes of G. I haemorrhage respond to conservative treatment. Haemosuccus Pancreaticus is a care cause of gastrointestinal hemorrhage and can prove difficult to diagnose.

OBJECTIVE

To highlight the carcinoma of the head of pancreas as a possible cause of massive upper G.I haemorrhage.

METHODS

Case 1: Mr. H. A., a 32 year old man who presented with repeated episodes of massive upper G. I. hemorrhage for which he was transfused on several occasions. He later presented in shock, was resuscitated and had emergency laparatomy. case 2: Miss B.O, A 30 year old lady presented with massive upper G.I hemorrhage not responsive to conservative measures. She had exploratory laparotomy and findings were bleeding pancreatic tumour that eroded into the duodenum.

RESULTS

Both patients were found to have pancreatic caranoma with bleding into the pancreatic ducts.

CONCLUSION

Haemosuccus pancreaticus may present as one of the early symptoms of carcinoma of the pancreas in young patients in our environment.

Day-case surgery for inguinal hernia: a multi-specialist private hospital experience in Nigeria

BACKGROUND

The growing popularity of day-case surgery derives mainly from its twin benefits of convenience and cost-effectiveness. It is particularly useful in treating inguinal hernia which remains one of the most common presenting surgical problems.

OBJECTIVE

To evaluate the results of inguinal herniotomy or herniorrhaphy done as a day-case.

METHODS

A cross-sectional study of 72 cases of inguinal hernia treated by day-case herniotomy or herniorrhaphy at Havana Specialist Hospital, Lagos, Nigeria between July 2002 and June 2004. Post-operative follow up ranged from 2 to 4 years. Patients with concurrent systemic illness that needed admission as well as those who preferred admission were excluded. Data including age, gender, hernia characteristics, type of anaesthesia, complications and outcomes were collected and analysed.

RESULTS

A total of 72 cases were studied. Only 4 were females, the remaining 68 were males. Ages 6 months to 60 years were affected with a mean age of 26.7 years and a peak incidence in the 21-30 years age group. The commonest complication was pain felt post-operatively by 62.5% of the study population. However, wound infection (seen in 11.2%) was the most significant complication. Other complications were wound and scrotal haematoma (8.3%), hemia recurrence (1.4%) and hypertrophic scar (1.4%). No mortality was recorded.

CONCLUSION

The study showed that post-operative pain is the commonest complication of day-case inguinal hemiotomy and herniorrhaphy. Wound infection was however the most common significant complication. The overall outcome was good.

Acute airway obstruction in the puerperium secondary to massive thyroid enlargement

Pregnancy is known to be thyrogenic and may exacerbate features of thyroid disease. We report the case of a patient whose pregnancy was complicated by respiratory symptoms following remarkable increase in size of a pre-existing goitre. She declined surgery during the pregnancy and it was rescheduled for after the puerperium. A week postpartum she developed acute airway obstruction which necessitated urgent thyroidectomy and management of tracheomalacia with a tracheostomy postoperatively. The effect of pregnancy on the course of her disease and the anaesthetic challenges in the face of limited airway equipment are highlighted.

An evaluation of the role of systemic antibiotic prophylaxis in the control of burn wound infection at the Lagos University Teaching Hospital

A prospective study was carried out on 61 patients to evaluate the role of systemic antibiotic prophylaxis in the control of burn wound infection. The patients were randomised into three groups: group 1 (n=21) received ampicillin and cloxacillin; group 2 (n=20) received erythromycin and genticin and a control group (n=20) received no systemic chemo prophylaxis. The burn wounds were similarly managed. Wound colonisation was determined from surface wound swab cultures and wound infection was determined from wound biopsy cultures and histopathology. The colonisation time (days) for the groups was 2.90+/-0.92, 3.15+/-0.77 and 3.05+/-0.83 for groups 1 and 2 and the control, respectively. The commonest organism isolated from contaminated wounds was Staphylococcus aureus. Wound infection was established in 5.70+/-1.70, 5.75+/-1.62 and 5.6+/-1.90 days for group 1, group 2 and the control group, respectively. There was no significant difference between wound infection time of control and group 1 nor was there such difference between the control and group 2 (P>0.05). The commonest organism infecting burn wounds in all the groups was Pseudomonas aeruginosa followed by S. aureus. There was however a significant difference between the treatment groups and the control (P<0.05) with regard to the percentage of infected wounds that grew P. aeruginosa, compared to those that grew S. aureus. It was concluded that systemic antibiotic prophylaxis is of no value in controlling burn wound sepsis, and might even favour the growth of P. aeruginosa in the burn wounds.

Use of direct Gram stain of stomach biopsy as a rapid screening method for detection of Helicobacter pylori from peptic ulcer and gastritis patients

Four hundred and thirty five stomach mucosal biopsies were taken from 145 consecutive patients (3 from each patient) during investigations for dyspepsia in three hospitals in Western Nigeria. The aim was to determine the best suited rapid screening method to aid fast diagnosis of ulcer/gastritis in this environment, using Gram stain, CLO test kit (urease production test) and culture methods. Eighty-nine (61.4%) biopsies were positive using Gram stain, 61 (42.1%) using CLO test kit and only 28 (19.3%) using culture. Based on the various limitations of CLO test kits and culture methods, Gram stain was adjudged the best suited rapid method. The clinical implication of this finding is discussed.

Use of direct Gram stain of stomach biopsy as a rapid screening method for detection of Helicobacter pylori from peptic ulcer and gastritis patients

Four hundred and thirty five stomach mucosal biopsies were taken from 145 consecutive patients (3 from each patient) during investigations for dyspepsia in three hospitals in Western Nigeria. The aim was to determine the best suited rapid screening method to aid fast diagnosis of ulcer/gastritis in this environment, using Gram stain, CLO test kit (urease production test) and culture methods. Eighty-nine (61.4%) biopsies were positive using Gram stain, 61 (42.1%) using CLO test kit and only 28 (19.3%) using culture. Based on the various limitations of CLO test kits and culture methods, Gram stain was adjudged the best suited rapid method. The clinical implication of this finding is discussed.

Bacterial flora of burn wounds in Lagos, Nigeria: a prospective study

A prospective study of burn wound sepsis was carried out on 31 consecutive patients with fresh burns. Wound swab cultures were assessed at weekly intervals for 5 weeks. The study revealed that while 96.7 per cent of burn wounds were sterile on admission, bacterial colonization reached 80.6 per cent within the first week after admission. Although the Gram-negative organisms, as a group, were more predominant, Staph. aureus (38.2 per cent) was the most prevalent organism in the first week. It was however surpassed by Pseud. aeruginosa from the second week onwards. Anaerobes were conspicuous by their absence. Similarly, beta-haemolytic streptococcus was not isolated from any patient. Proteus mirabilis was unusually preponderant, forming 19.4 per cent of all isolates. The antibiotic sensitivity pattern showed resistance of most of the organisms to ampicillin. Only 15 per cent of staphylococci were sensitive to cloxacillin. Most of the organisms cultured (93.5 per cent) were sensitive to ceftazidime.